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Monday, January 26, 2009

I came across my comprehensive exams for my PhD this morning and had a fun time reading through the essays I wrote. One of the questions for my U.S. Environmentalism exam asked me to connect my interest in midwifery with my environmental interests. I've reposted my response below. Keep in mind that this was part of an 8-hour long sit-down exam (and another 8 hours the day before for my other field of study), so the grammar and organization won't be as polished as they would be in a research paper.

Question:Among the graduate students with whom I’ve dealt at Iowa since 1992, you are rare in that you come with another profession--midwifery--already in place. I’m aware as well that another part of your written comprehensive examination will deal with medical issues within American culture, and having read your position paper, I see how your repositioning of American Studies as a field depends to some extent on your own professional background and experience. My questions here are, not surprisingly, more specifically related to the connection between your two fields: how do you link your environmental interests with your practice of midwifery? How would you construct a justification, at once intellectual and personal, for the practice of midwifery in this age seemingly dedicated to increasingly scientific intervention of all kinds? What are the implications--for our concept of the environment or for “environmental studies” in general--of your “non-traditional” medical background? How, in your preparation for this exam, did your environmental reading and your medical reading--or your actual practice of midwifery--reinforce one another? You are not obligated to answer all four of these sub-questions in order to answer this overall question successfully; rather, the sub-questions are intended only as guides to your meditation as you illustrate the link between your interest in midwifery and your interest in, and concern for, the biotic environment.

The Case for Biodynamic Birth

When I first chose my two exam fields, I must admit that I didn’t see very many connections between the two at all. They were just two areas I was interested in. After all, the history of medicine and especially the history of childbirth and midwifery are fairly “internal” fields, often focused on the body and on the lived experience of birth. On the other hand, most of my environmental history courses had concentrated on “external” problems: pollution, resource depletion, overgrazing, erosion, or wilderness preservation. Some of the first connections I started seeing between the two fields were in areas of disease and public health. Historical susceptibility to certain diseases was contingent upon one’s environment (in the sense of one’s physical surroundings). For example, I learned that polio became a real threat only when sanitation improved. Some diseases affected poor urban dwellers disproportionately, such as cholera, while others were more dependent on the immediate geography and climate, such as yellow fever. Hence cholera was initially understood as a moral problem, while yellow fever never acquired the same moral valence.

One of the first books I read that explicitly made a connection between environmental issues and childbirth was The Farmer and the Obstetrician (2002), by Michel Odent. (It’s not on my reading list but it should be!) Odent is a French obstetrician who was in charge of a maternity hospital in Pithiviers in the 1970s and 80s. With the help of midwives, he transformed the hospital rooms into homelike birthing spaces and eliminated most of the drugs and procedures common to Western childbirth. His focus was to discover the basic physiological needs of laboring women and to design rooms than enhanced, rather than slowed down, labor. The rooms had no delivery bed, but low comfortable mattresses and chairs. He was the first to introduce large pools of warm water into a hospital for women to labor and birth in. Women received no pain medications and rarely needed surgical or pharmacological assistance to give birth. He argues that the basic needs of women in labor are privacy, freedom from feeling observed or fearful, feeling secure, and not having their neo-cortex or “thinking” part of the brain overly stimulated. Odent has been extremely influential in childbirth reform and now heads a Primal Health Research Center in London that explores the connections between what happens at the period surrounding birth and human health and behavior decades after birth.

In The Farmer and the Obstetrician, Odent points out the connections between industrialized farming and industrialized childbirth, and between the organic farming and natural childbirth movements. He argues that industrialized farming and industrialized childbirth are two aspects of the same phenomenon: both are “typical ways to deviate from the laws of nature” (19). One is about non-human life, while the other concerns humans. Let me first explain what Odent means by industrialized farming and childbirth. The main features of industrialized farming, which arose in the early 1900s, are feeding cattle animal protein, heavy mechanization, synthetic chemicals, monoculture, hormone/antibiotic treatment, and scientific feeding. He defines industrialized childbirth as a phenomenon largely beginning in the 20th century with the transition from home to hospital births, from midwives to obstetricians, routine forceps and episiotomy deliveries, manual extraction of the placenta, heavy use of pharmacologic agents for pain relief and for controlling labor, machinery to monitor labor, routine IVs, and a recent explosion in cesarean section rates.

So what makes these two phenomena similar? How might the problems facing the environment inform my midwifery studies? Odent explains that industrialized farming and childbirth are both manifestations of a human desire to dominate nature. Both of these methods involve intense technological and material investment, were adopted quickly with little knowledge of their long-term effects, require large amounts of energy and intervention to maintain a functioning system, and rely on controlled manipulation of various factors.

Let me explain more in depth these similarities by providing some examples. In industrialized childbirth—which characterizes most births that take place in modern hospitals—very few women give birth physiologically, without large amounts of external manipulation and intervention. For example, a woman in labor entering a hospital will usually be required to change her clothes, receive an IV, have a vaginal examination to determine cervical dilation, and wear monitoring belts that record the contractions and baby’s heart beat on a computer printout. Wearing these monitors requires women to stay still, preferably in bed, as to not disturb the monitors. This has the effect of slowing labor and making it more painful. Industrial solutions to these problems include narcotics and anesthesia (which often renders women even more immobile and slows labor further) and artificial hormones to speed up labor. Because adrenaline directly inhibits the release of oxytocin, the hormone that causes the uterus to contract and labor to progress, women who are fearful, insecure, cold, or surrounded by strangers and bright lights will often experience a delay in labor. In addition, lying down often contributes to slowed or stopped labor, in part because the baby must work against gravity and the woman cannot move her body to help the baby into a more favorable position. Because normal physiology is often interrupted in the industrialized process, surgical interventions are frequent. Today over one quarter [now close to 1/3 as of 2006] of all American women undergo abdominal surgery to give birth. Most receive one or more types of pain medication, and a majority receive the synthetic form of oxytocin some time during labor or immediately postpartum.

Similarly, industrialized farming replaces normal biological “physiology” with artificially controlled environments. Monoculture of crops often leads to soil depletion and insect damage. Chemical fertilizers and pesticides are a temporary solution, but often heavily fertilized soils lose their fertility and must rely on further doses of chemicals in order to produce crops. Mechanization compacts the soil, while heavy plowing can lead to soil erosion. As with industrialized childbirth, certain actions have a “cascade” effect, with unintended consequences requiring even more intervention and energy. These systems are not infinitely self-sustaining, but require heavy amounts of energy investment in the form of mechanical labor and petroleum-based chemicals. In her essay on “Farming and the Landscape,” Jane Smiley critiques modern industrial farming because it has little biodiversity (animal, plant, or human) and must be cared for 24/7. The basic assumption of “new agriculture” that she finds problematic is that humans can and should manipulate nature at its very foundations for the sake of feeding as many people as possible. Instead she advocates a complex system of agriculture—biologically complex—that takes care of itself (Placing Nature, 1997).

The most interesting idea to arise from my environmental readings in regards to midwifery and childbirth is that of biodynamism. Odent himself uses the term in his book. He proposes “radically new attitudes” (105) towards childbirth based on biodynamics. He defines the term as “understanding the laws of nature and working with them” and as understanding the true physiological process, not just the culturally or medically controlled one (133). How does this compare to definitions of biodynamics as it relates to the environment?

During his career, Aldo Leopold gradually evolved towards a biodynamic ethic that respected the interactive, complex processes of nature. During the first part of his career, he would routinely shoot wolves and prevent forest fires—in other words, micro-manage the land—because the prevailing wisdom taught him that predators and fires were undesirable. He gradually learned that controlling these elements led to a cascade effect of unwanted consequences, such as exploding deer populations and terribly destructive fires. He advocated “the recognition of invisible interdependencies in the biotic community....Wildlife management...has already admitted its inability to replace natural equilibria with artificial ones, and its unwillingness to do so even if it could” (237). By 1936-37, he had come to a mature understanding of the complex processes of a biotic community (See his essays “Threatened Species,” “Means and Ends in Wild Life Management,” and “Conservationist in Mexico” in River of the Mother of God.) A more recent definition of “ecological health” by Jim Karr and quoted in Grumbine’s Ghost Bears further explains a biodynamic approach:

A biological system—whether it is a human system or a stream system—can be considered healthy when its inherent potential is realized, its condition is (relatively) stable, its capacity for self-repair when perturbed is preserved, and minimal external support for management is needed.

Grumbine comments that these standards are “serviceable at all scales, local, regional, global, because they embrace an ecosystem perspective” (184).

Several of my environmental readings illustrated how biodynamics plays out in specific situations. Rick Bass, writing about the reintroduction of wolves into Montana (outside of the national parks), noticed that the resurgence of wolf populations had a positive and unanticipated cascade effect on both plant and animal communities. The presence of wolves changed grazing patterns in their prey, which had a positive impact on areas that used to be overgrazed. In addition, once certain areas such as stream banks could recover from overgrazing, important native plant species re-established a foothold (The Ninemile Wolves, 1992). When rancher Dan O’Brien converted his South Dakota cattle ranch back into bison habitat, he learned that reintroducing one part of an entire ecosystem had a positive multiplicative effect. The soil became healthier because of the grazing patterns of the bison, which helped promote native prairie grasses and more plant biodiversity. Bison were more self-sustaining than cattle; they required far fewer external expenditures such as feed, water, vaccinations, or shelter in extreme weather. In addition, he noted that bison meat is much healthier for human consumption than beef (Buffalo For the Broken Heart, 2001). With the addition of wolves and bison, the biotic community became more stable and self-sustaining.

The principle of biodynamics can be a powerful framework for understanding and advocating changes in childbirth as well as in the environment. In fact, midwives and childbirth reformers have been following biodynamic principles even before Michel Odent applied the term to childbirth in 2002. A key principle of midwives, especially homebirth midwives who work outside of an institutional setting, is to promote and facilitate the natural process whenever possible. For example, instead of requiring laboring women to forego food and drink and accept an IV line (in case they have an emergency surgery under general anesthesia and aspirate their vomit), homebirth providers will encourage a woman to eat and drink freely as she desires. This keeps a woman from becoming dehydrated, hungry, or exhausted and prevents possible complications such as fluid overload or electrolyte imbalance. It also preserves the body’s normal physiology of digestion, thirst, and elimination.

Another example of biodynamics at birth is how homebirth midwives often approach slow or prolonged labor. The industrial/technological solution is to artificially stimulate labor with hormones, break the amniotic sac in the hopes of speeding things up, or to resort to an operative delivery. These approaches all have a cascade of consequences and frequently require additional drugs, interventions, or monitoring. A biodynamic approach, on the other hand, would determine first whether or not the “slow” labor is a problem. Most often, a midwife will encourage her client to rest if she is tired and labor slows down. A biodynamic caregiver might also seek to eliminate anything that causes the release of adrenaline, which has an antagonistic effect on the hormone oxytocin, which I described earlier. This could include asking certain people to leave the room, raising the room temperature, dimming the lights, giving the woman some privacy, or ensuring that she is not hungry or thirsty. They might also encourage the woman to move or change positions, based upon what feels good to the woman. These solutions all rely on the woman’s normal physiology to help labor progress, rather than substituting an artificial solution that often requires further management or intervention.

There is a measurable difference in outcomes between biodynamic and industrial approaches to childbirth. For example, the midwifery practice at The Farm, Tennessee, had a 1.4% cesarean rate between 1971-2000, compared to a national rate of over 27% [now 31.1%]. Infant mortality rates are comparable. (The Farm’s statistics include situations labeled “high-risk”—such as breeches, twins, or premature babies). Both systems have the same end “product”: living mothers and babies. However, the biodynamic system relies on the woman’s own complex physiology whenever possible to accomplish the birth, rather than on external hormonal, pharmacological, or surgical procedures. A biodynamic system is simply managed (if at all), inexpensive, and diverse, while an industrial system of childbirth is complex in its management, expensive, and fairly uniform in terms of interventions and procedures (see Davis-Floyd’s Birth as an American Rite of Passage and parts of my position paper).

A critic of homebirth midwifery might ask, “What’s the fuss all about? After all, most women and babies are healthy and the current hospital/obstetrical system works just fine.” This is the same thing one might comment about industrialized farming: yes, it’s expensive and requires vast amounts of chemicals and monitoring, but it has produced a marvelous amount of cheap, abundant food. And why bother preserving wilderness places? Most people never even visit a wilderness and survive quite well in human-mediated environments. Aldo Leopold and John Muir have provided me with answers to those questions in their wilderness philosophies. Wilderness advocate John Muir advanced a utilitarian case for wilderness common to 20th century ecology—that wilderness should be preserved as a place where natural processes continue to function unimpaired. Several decades later, Leopold argued for “Wilderness as a Land Laboratory” (River 1941). He acknowledges the recreational value of wilderness, but argues that it has even greater scientific value as a control for ecological health. In order to determine what is truly natural or healthy for a biotic system—a “base-datum of normality” (288)—he proposes studying wilderness as controls in comparative studies of used and unused land. Wilderness areas are perfect examples of healthy organisms that have a “capacity for internal self-renewal known as health” (287).

This control argument could be a powerful rationale for preserving homebirth and midwifery. One could argue that very few institutional care providers know what undisturbed birth looks like. When the vast majority of women birth in an unfamiliar location, receive some form of pain medications, are tied to IV lines and monitors, and receive artificial hormones during labor, very few caregivers have ever seen a truly physiological or biodynamic birth. (This has been called “natural” or “normal” birth, but those terms are quite problematic, as natural birth has become associated with the lack of pain medications, and recently has come to mean anything but a cesarean section.) It would seem logical to argue that in order to understand pathology, one must first understand physiology. This is not to say that homebirths are automatically free of any external influences. As Brigitte Jordan shows in her anthropological investigation of birth cultures, Birth in Four Cultures, birth can never be culture-free. However, some birth cultures do promote more physiological experiences than others. The key to determining which practices disturb physiology or upset biodynamism is to compare the birth (or a biotic community) against Karr’s criteria: ability to realize its inherent potential, stability, capacity for self-repair when disturbed, and minimal external support. This is a question Cronon addresses in Changes in the Land. He argues that Native Americans used and changed the land, but that there was a qualitative difference between Native American and European American land use. Native American land use was infinitely sustainable and preserved biodiversity, while European land use patterns quickly deteriorated biotic diversity and soil health.

Michel Odent points out that our ultimate priority shouldn’t be to transform certain farming techniques or birth practices, but to ensure the future of our civilization. He notes that industrialized farming and childbirth both show a “weakened ecological instinct” that impairs our capacity to love. How does this occur in childbirth specifically? He explains that until recently, a woman couldn’t become a mother without releasing a complex cocktail of “love hormones” (including oxytocin and prolactin) at the time of birth. However, industrialized childbirth has disrupted the normal flow of birth hormones. When anesthesia, narcotics, artificial hormones, cesarean surgery, or immediate separation of the mother and baby are present, the mother’s hormonal system is altered and usually the level of hormones released diminishes significantly. Odent is concerned with the long-term implications of any practice that disturbs these vital love hormones, because certain birth practices have been linked to higher rates of autism (induction of labor), suicide (surgical birth, asphyxiation at birth), and anorexia nervosa (presence of a cephalohematoma at birth). (A collection of studies documenting these associations are available through the Primal Health database.) All of these disorders are what Odent terms an “impaired capacity to love”—oneself, others, or nature. Aggressiveness towards non-human life, including the land, is a symptom of that impaired capacity. He concludes that “the current industrialization of childbirth should become the main preoccupation of those interested in the future of humanity” (137-38). Odent is not the only person I have read who insists that our relationship to our bodies and to the earth is connected. In chapter 7 of Unsettling America, “The Body and the Earth,” Wendell Berry argues that there should be a profound resemblance between our treatment of our bodies and of the earth; you can’t simultaneously devalue the body and value the soil.

A final useful concept I have gained from my environmental studies is that of humility and restraint in the face of the unknown. In his book You Can’t Eat GNP: Economics as if Ecology Mattered (2000), Eric Davidson argues that it’s silly to replace something that already works well with something that’s technologically complex and enormously expensive. He comments:

Technology is unlikely to find substitutes for these essential services provided by forests....Simply keep the climate from changing rapidly and keep the forests in good health, and we will have a proven natural ‘technology’ that we know will provide what we need. Start tinkering by replacing forests with new, unproven technologies, and we take a giant risk that is unnecessary and imprudent.

He provides several examples of already available technologies and the proposed “improved” solutions: forest watersheds that purify water, versus pumped and purified groundwater; forests’ beneficial effects on climate to regulate temperature and rainfall, versus giant space shields orbiting over the earth (92). Aldo Leopold likewise recommends caution in the face of the unknown: “If the biota, in the course of aeons, has built something we like but do not understand, then who but a fool would discard seemingly useless parts? To keep every cog and wheel is the first precaution of intelligent tinkering” (Quoted in Davidson 167). I wish to conclude with a quote from the famous Dutch obstetrician G. J. Kloosterman, who was an ardent supporter of midwifery and homebirth:

Spontaneous labour in a normal woman is an event marked by a number of processes so complicated and so perfectly attuned to each other that any interference will only detract from the optimal character. The only thing required from the bystanders is that they show respect for this awe-inspiring process by complying with the first rule of medicine--nil nocere [do no harm].

16 comments:

seriously, how do you have time to write these incredibly interesting and well thought of essays? no really... I want to know the secret! I am a mother of 2.5 and I do think you could not only write circles around me. but probably run them too.good grief!

This is excellent! Thanks very much for such a good essay. Birth has a funny way of showing us how the outside world and environment is inherently tied to our inside environment. It's the marvel of how women's bodies can turn anything into milk, but whatever is in women's bodies goes into that milk. I'm really enjoying your blog and have found really great resources here. Please keep up the great work.

I live in a an area rich with agriculture and viticulture, and in the last few years there has been something of a biodynamic farming movement. I find it fascinating.It is neat to see you tie two very environmentally healthy practices together this way.Great paper.

Have you read any of Vandana Shiva's work? (I'm sure you've come across her). She wrote about the parallel between industrialised childbirth and industrialised farming in "Ecofeminism". An absolutely terrific read if ever you find the time :)

I enjoyed reading this. I read an article that I thought you would find interesting and thought provoking. I was a bit surprised. It is at: http://www.msnbc.msn.com/id/28857953/ is talks about the "rise in infant suffocations tied to bed-sharing".

I love it. Have you contributed any of your research to The Big Push For Midwives? I think they could benefit from the eloquence of your writings regarding birth & the necessity for women to be allowed alternatives to the medical model of care.

Your writing has put on a very important notion of biodynamic. As a teacher, i also felt that this biodynamism is closely related to education (how children learn by themselves). Thank you for such a good inspirational writing and ideas.